With advanced brain imaging techniques and brain functional tests, researchers at the Albert Einstein College of Medicine have presented findings from an interesting study that suggests that repeatedly heading a soccer ball increases the risk for brain injury and cognitive impairment. You can read a summary of the study and see a brief video interview with one of the study authors here.

The study authors used an advanced MRI-based imaging technique on 38 amateur soccer players (average age: 30.8 years) who had all played the sport since childhood. They were asked to recall the number of times they headed the ball during the past year. Researchers ranked the players based on heading frequency and then compared the brain images of the most frequent headers with those of the remaining players. They found that frequent headers showed brain injury similar to that seen in patients with concussion, also known as mild traumatic brain injury (TBI).

The interesting part (and somewhat scary) is that by combining the MRI findings, brain functional tests, and number of headers the players recalled in the past year the researchers were able to come up with a threshold for brain injury risk in these adult players. The number: about 1,000 headers annually. That number is really not as big as it seems. Let’s say you play 30 weeks out of the year, three times per week. It comes out to about 11 headers per game or practice session. That’s a number easily reached by many defenders and other field players.

The authors then go on to point out some parallels between this study on headers and studies performed on throwing injuries in Little League players that ultimately led to pitch count rules now adopted by Little League Baseball.

Here’s my take, as a former player, current parent of two soccer players, and current team physician with 18 years of experience:

* This paper, along with other mounting evidence, points to a possible cause-and-effect relationship between repeated headers and mild brain injury similar to a concussion. We need to take this evidence seriously.

* But still, more evidence is needed. We need to study this issue carefully in a large prospective clinical trial involving the youth age groups. This type of study would likely involve multiple study sites, following players from the start of a time period over one or more playing seasons. The baseball studies were like this. They take years to complete.

* My feeling is that if there is a threshold of headers for the younger player, studies will likely show that it is much lower than 1,000 headers per year. The young brain is more susceptible to injury than the adult brain.

* My feeling also is that the threshold for female athletes will be lower than male athletes. There is convincing evidence that gender differences exist, with girls/women sustaining concussion with lower forces.

So we’re not ready to assign a “header count” for young soccer players but the youth soccer coach would be wise to structure practice sessions to minimize heading. This study from the Albert Einstein College of Medicine doesn’t give us all the answers but it most surely begs us to ask the tough questions.

(Dev K. Mishra is the creator of the SidelineSportsDoc.com injury management program for coaches. He is an orthopedic surgeon in private practice in Burlingame, Calif. He is a member of the team physician pool with the U.S. Soccer Federation and has served as team physician at the University of California, Berkeley. This article first appeared on SidelineSportsDoc.com.)

For youth soccer, especially at the younger age groups, it would make sense to get away from GK's punting the ball. If the GK's were distributing with their feet or hands and finding their backs and coming out of the back with possession it would limit the opportunities to head the ball. Too many coaches are relying on a big punt or long ball in lieu of possession and keeping the ball on the ground. I would love to see header numbers for some professional teams, i.e. Arsenal or Barcelona.

Todd Leavitt

commented on: January 12, 2012 at 10:34 a.m.

What is considered a "Header" in the study mentioned? Is any contact with the head counted? Is juggling with the head considered part of the number? How about a light, headed pass. If you toss a ball to a player in practice to work on technique is that considered the same as a defensive clearance header from a punt? Also, at what age does the potential for injury reduce?

Dave Howard

commented on: January 12, 2012 at 12:26 p.m.

Personally I've always been concerned with heading the ball and youth players. Personally having coached youth players from 8 - 19, I have always been concerned when and how to introduce heading to the players and how to practice the skill. Heading is part of the game, however, should be introduced and practiced as the skill level warrants. Additionally, I don't agree with juggling in practice using headers. I do believe short skills development of heading for players 12+ is OK but should not be done excessively.

Terry Hughes

commented on: January 12, 2012 at 1:02 p.m.

As a youth coach I have had parents of players instruct their children not to head the ball. I first encountered this about 10 years ago, after a study had been completed somewhere in Europe. I agree with the Dr.,we need to take this stuff seriously, but the test he speaks of and which was summarized in the NY Daily News a couple of weeks ago does not sound very scientific to me. The more this information gets out across the soccer moms of america, the more we're in danger of losing players unnecessarily. I'd like to see the soccer governing bodies commission an independent study on this and to offer their endorsement. Parents who may have never played themselves are not going to wait the many years it takes to produce the results and will find other options at 4 & 5 years old. We need a proactive approach with visible stars such as Amy Wambach and recently retired Brian McBride of the US Soccer World whose careers were made by their ferocious and courageous ability to go up and win headers. Let's study their brains , and broadcast those results. That will carry much more weight than any study who asked a bunch of 30 year old rec players how many times they recalled heading the ball. Really now, give me a break. Did they remember how many beers they drank after the game too? Maybe I have headed the ball too many times myself to be worried about this.

Kent James

commented on: January 12, 2012 at 2:08 p.m.

Very informative column, and certainly, the subject requires more study. I like Joseph's idea of eliminating punts at the young ages, since it not only eliminates the most difficult/dangerous headers (and ones which young kids justifiably fear) but it also has the advantage of encouraging building the play out of the back. I have to chastise the good doctor for not speaking the truth about the gender differences in heading; he should not pull his punches (since they are just figurative, and have no impact on brain injuries); girls have a lower threshold for concussion because boys are more hardheaded! (but we knew that already....).

Lucia Steinlage

commented on: January 12, 2012 at 2:28 p.m.

Football, hockey, baseball, and lacrosse, to name a few, all require helmets. Would it spoil the sport to wear some form of head gear that would absorb the impact of a ball but not change the players intention for the ball? It really should be a no-brainer.... or our players will be.

Robert Waffle

commented on: January 12, 2012 at 4:18 p.m.

Thank you Lucia for bringing up the issue of headgear. My daughter suffered three concussions, two from soccer and one from field hockey (another "girls" sport that mis-guidedly does not require headgear because it's a "girls sport") and was subsequently not allowed (by me, not her coaches) to walk onto the field without head gear. I wish I would have acted sooner, before the concussions. It's not just contact with the ball, but with other heads, body parts, and the ground. My daughter's travel coach urged the use of head gear, but did not require it. Unfortunately, kid's think it's not cool. Better to be a dork who can think and not have headaches than to be cool and suffer life-long irrepairable brain damege. Also better to change the sport in this type of small way than to change it by banning "heading" as some are calling for. Lots of great discussion re concussions lately, but, unfortunately, mostly on recovery afterwards rather than prevention.

Lucia Steinlage

commented on: January 13, 2012 at 12:27 p.m.

seeking paradigm shift on how cool headgear is...

lorenzo murillo

commented on: January 13, 2012 at 5:02 p.m.

Its reports like these one of the reason soccer will never grow in this country. The person writing this article has an MD and immediately he is a expert in the subject. Think about this, if heading a ball will cause brain injury, wouldn't you have lots of people around the globe with brain issues? Also, many of the contact injuries that occur in soccer in the US (and US ONLY), occur to a lack of athleticism of the players, especially girls who are not taught how to header correctly and ensure they and other players do not get hurt. Most player in the US no longer play in the sandlots, therefore not developing the motor skills require to play a dynamic sport like soccer.

Bo Cutter

commented on: January 30, 2012 at 5:40 p.m.

Heading is a concern, but the slides I have seen say the bigger contacts like head to elbow are a much bigger deal. All the associations should sit down with the refs and have a serious conversation about high elbows or people diving in to header after a player has established his space. Those should be automatic cautions at the younger age- even if there is no contact, if those ebows come up-caution it. Players can always learn to play rougher when they are older. Soccer is playing with fire by not addressing these issues.